Care Assessment
Based on your answers, best practices, products, and services will be recommended that could help with your unique caregiving situation.
Care Assessment
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Who are you doing this assessment for?
*
Who are you doing this assessment for?
*
Select
Father
Client
Mother
Son
Daughter
Husband
Wife
Grandmother
Grandfather
Myself
Other
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What is your
(relationship)
's age?
What is your age?
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Has your
(relationship)
fallen or nearly fallen in the past year?
Have you fallen or nearly fallen in the past year?
Yes
No/I don't know
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Do you have an accurate and updated list of all medications that your
(relationship)
is taking?
Do you have an accurate and updated list of all medications that you are taking?
Yes
No
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Do you have a list of all of the doctors and medical providers your
(relationship)
has seen in the past year?
Do you have a list of all of the doctors and medical providers you have seen in the past year?
Yes
No
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Who else is involved in your
(relationship)
’s caregiving situation?
Who else is involved in your caregiving situation?
Select
Select Caregivers Involved
Family
Friends
Care Manager
Non-medical, agency hired caregiver
Non-medical, self-hired caregiver
Nurse/Medical caregiver
Family: Spouse
Family: Children
Family: Parents
Family: Extended
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Have you added all planned care activities for your
(relationship)
to a central calendar?
Have you added all planned care activities to a central calendar?
Yes
No
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Do you have Advance Directives, end of life, living will, or other care plan documents for your
(relationship)
?
Do you have Advance Directives, end of life, living will, or other care plan documents?
Select
Yes
No, but we’ve had the conversations
No, and we have not had the conversations
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In what zip code is your
(relationship)
currently living?
In what zip code are you currently living?
Zip Code
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In what setting is your
(relationship)
currently living?
In what setting are you currently living?
Select
At home, alone
At home, without caregiving support (with others, but they can’t provide care)
At home, with caregiving support
At home, with 24x7 caregiving support
Hospice facility
Skilled nursing facility
Assisted living facility
Memory care facility
Independent living or age-restricted retirement community
Nursing home
Group Home
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What daily activities does your
(relationship)
have trouble with, could use help with, or you are worried about them performing?
What daily activities do you have trouble with, could use help with, or are worried about performing?
Select
Select Activities of Daily Living
Bathing
Getting in and out of bed
Getting dressed
Laundry
Grocery shopping
Meal preparation
Medication management
General house maintenance
Lawn/yard maintenance
Snow removal
Paying bills
General transportation/driving
Ambulation/getting around the house
Ambulation/going up and down stairs
Other
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What challenges or medical conditions does your
(relationship)
have?
What challenges or medical conditions do you have?
Select
Select Medical Conditions
Alzheimer's Disease/Dementia
Arthritis
Blindness/Vision problems
Blood Pressure/Hypertension
Cancer
Chronic Pain
COPD/Lung disease/Asthma
Deafness/Hearing problems
Depression/Mental health
Diabetes
Falls
General mobility/Ambulation (may need a cane, walker, wheel chair, help with stairs)
Heart Disease/CHF/Heart attack
Hip or Knee problems
Incontinence
Kidney Disease/Dialysis
Obesity
Physical decline (weakness, fatigue, difficulty getting around)
Stroke
Tremors, Parkinson’s
PTSD
Hypoxia at Birth
Other
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What concerns do you have about your
(relationship)
's caregiving situation?
What concerns do you have about your caregiving situation?
Select
Concerns
Equipment needs (tub bench, elevated toilet seat, walker, etc.)
Financial concerns
Homebound (unable to leave home by themselves, unable to drive)
Needs new housing option (current location is not safe or requires more care than can be provided)
Diet/Doesn't eat as well or as much as they should (poor nutrition)
Social isolation
Medication challenges (remembering refills, taking on time, paying for)
Safety concerns (falls, difficulty showering, forgetfulness with cooking)
No emergency backup plan (NO plans for what would be done if current situation no longer works)
Supportive services are needed (needs help with bathing, needs help with housecleaning, etc.)
Trouble managing medical care (making/keeping appointments, ordering medications, etc.)
Professional medical needs (therapy, wound care, IV's)
Financial: Does not have money
Financial: Unable to manage money
Current Housing Concerns
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